How We Got Here & What’s Next for the AHCA

It’s been quite the week for health care here in Washington. The American Health Care Act, House Republicans’ effort to repeal and replace the Affordable Care Act (ACA), was first declared dead then subsequently brought back from the depths before passing in the House last Thursday. In a little more than a week, the political dynamic on Capitol Hill was turned on its head and much has changed since March 24, when Republican leadership pulled the AHCA due to a lack of support from both the conservative bloc of members in the Freedom Caucus and a smattering of moderates. Below, you’ll find a brief summary of some of the major events and changes to the AHCA since the bill was pulled in March, as well as a bit of insight into what may play out once the AHCA arrives in the Senate. Also, don’t forget to take a look back at our March blog for a refresher on how the AHCA could impact Medicaid, private insurance, and public insurance exchanges, and be sure to read NACHC’s statement on House passage of the bill.

Major Changes in the AHCA Since March

Early last week, it looked as though Representative Tom MacArthur’s amendment to allow states to apply for waivers and opt out of several ACA protections, including rules requiring minimum plan benefits, limits on charging older Americans more, and the ban on charging sick people more, may well have doomed House Republicans’ efforts to pass the AHCA. The amendment, which allows states to opt out of ACA protections as long as their alternative ideas would lower premiums, attracted the support of many Freedom Caucus members who opposed the initial draft of the AHCA, but also sent many moderate Republicans running for the hills at the prospect of voting for an age tax on senior citizens and a sick tax on folks with preexisting conditions. The MacArthur amendment also exempted Members of Congress and their staffs from the state waivers; however, that provision was taken out of the bill in a separate piece of legislation passed immediately after Thursday’s vote.

On Tuesday, the AHCA appeared to be on life support when Rep. Fred Upton came out in opposition to allowing states to waive protections for preexisting conditions. As a former chairman of the Energy and Commerce Committee, which has wide jurisdiction over health care policy in the House, Rep. Upton is a respected moderate voice within the GOP on health care issues, and his temporary defection was notable. In addition to concerns about preexisting conditions, Rep. Upton stated the amount of money included in the AHCA for “high risk pools,” which fund care for individuals who can’t afford or access insurance coverage due to their health, wasn’t high enough ‒ despite the claims by Republican leadership that the bill contained $100 billion for states to cover the sickest, most expensive customers.

After a bit of deal-making, and intense pressure from House Republican leadership and the White House, Wednesday brought about a change of heart from Rep. Upton, and helped turn the tide of opposition from moderates into a wave of support that eventually resulted in the passage of the AHCA. In an effort to ease the pain for folks with preexisting conditions who could be harmed by the AHCA, and in exchange for his vote, Rep. Upton negotiated an additional $8 billion to lower costs for the sickest and costliest Americans. The additional money, which outside experts say is not enough to accommodate the number of folks who could be pushed off insurance rolls and into high risk pools, was enough to convince wavering moderates to support the bill.

What’s Next in the Senate?

The AHCA now moves to the Senate where it faces an uncertain future. Senate Republicans can afford to lose just two votes – a slim margin given that both moderate and conservative Senators have expressed concerns with the House bill. A number of Republican Senators have already expressed concerns and apprehension with the House-passed legislation, including Senator Lindsey Graham (R-SC) who tweeted, “A bill – finalized yesterday, has not been scored, amendments not allowed, and 3 hours final debate – should be viewed with caution.” In addition, Senator Rob Portman (R-OH) issued a statement, saying “I’ve already made it clear that I don’t support the House bill as currently constructed because I continue to have concerns that this bill does not do enough to protect Ohio’s Medicaid expansion population, especially those who are receiving treatment for heroin and prescription drug abuse.” In other comments made Thursday shortly after the AHCA passed the House, Senator Lamar Alexander (R-TN), Chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee and someone who will have an important role in how this bill is shaped in the Senate, stated in a floor speech, “We’ll carefully consider the legislation passed by the House. We will work together carefully to write our own bill. We will make sure we know what our bill costs when we vote on it… We will get it right and then we will vote.” Thus signaling that Senate Republicans are planning a slower, more deliberative process than the House, at least at this time.

In terms of process and procedure, we should note here that Republicans are attempting to pass the AHCA under the budget reconciliation process, which only requires a 51-vote majority in the Senate to pass a bill, rather than the normal 60-vote standard. More importantly, passing a bill through reconciliation subjects the legislation to the so-called “Byrd rule,” meaning the bill’s primary purpose must be changing the federal deficit, and not making major policy changes. Many observers believe that MacArthur amendment, and several other provisions of the House bill, may be stripped out in the Senate due to violating the Byrd rule. Simply stated, significant portions of the House bill veer into the realm of making large policy changes whose primary purpose, it will be argued, is not budgetary in nature. It remains to be seen how much of the AHCA will be ruled out due to the Byrd rule, but rest assured that you’ll hear this phrase quite often as the Senate begins debating a repeal of the ACA.

While Thursday’s vote gave the AHCA effort a major shot in the arm, it’s clear major hurdles remain before ANY health care legislation can be signed into law. As the Senate moves forward in its efforts to repeal and replace the Affordable Case Act, the Federal Affairs Team here at NACHC will continue to provide timely updates and analysis. As always, please continue to follow NACHC’s Twitter and Facebook accounts for up-to-the-minute news and insights, and visit the Health Center Advocacy Network site to find out what steps you can take to get engaged.